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li <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> 1601 E.. HAZEL T ON AVE.; STOCKTON, CA <br /> h <br /> Telephone (209) 466-6781 rTIN- <br /> PERMIT <br /> EXPIRES 1 YEAR FROM DATE ISSUED �v <br /> { (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> sw <br /> made in compliance with San Joaquin County Ordinanc 549 for age or o. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Dist ct. �U <br /> Job Address City Lot Size SOX t9 ' PM <br /> Owner's N e 4� -' 1 r Address <br /> Contractor Address —License No. Phone <br /> TYPE OF WELL/PUMP: ',';NEW,WELL ❑,. __WELL REPLACEMENT,,❑ DESTRUCTION O <br /> _y _ <br /> PUMP INSTALLATION'❑' SYSTEM REPAIR ❑� OTHER ❑— <br /> DISTANCE REST: SEPTIC TANK SEWER LINES DISPOSAL.FLD. PROP. LINE <br /> DATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WEL OBLEM AREA CONSTRUCTION SP NS <br /> Industrial ❑ Open Bottom ❑ Mante Dia. xcavation t Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Typ asing Specifications <br /> ❑ Public ❑ Other .t elta Depth of Grout Type of Grout <br />' � F <br /> El Irrigation _._4ppr epth 13 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ of Pump H.P. State Work Done <br /> —Sealing <br /> Well Destruction ❑ Well Diameter � g �MaterialltoP 50'1 <br /> � .,�. <br /> Depth FillerIBe <br /> `Material• low 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION iNo septic system permitted if public sewer is <br /> available within 20O feet.) <br /> Installation will serve: Residence Commercial Other <br />! <br /> Number of living units: Number of bedraoms� <br /> j Character of soil to aapt of 3 feet: 1 Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> f <br /> PKG. TREATMENT PLT. 0 a Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ,x <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ID Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITSNumber <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑+ I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. `* <_`: <br /> Home owner or licensed agent's signature certifies the following: "I certify that,in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> i certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- . <br /> tionlaws of Ca fornia." �9 <br /> The applicant ust call for all required inspections. Vimplete dra g on r arse side. <br /> Ie: Date: <br /> Signed <br /> ! OR DEPARTMENT USE ONLY f� <br /> ApplicafnAcepted by I� Date �'� `-'� Area <br /> Pit or Grout Inspection by 'F Date Final Inspection by Date <br /> i. �y <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ;❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMiT'NO. <br /> i INFO CASH f <br /> + EH 13-24(REV.1/a 5) <br /> EH 14-28 'f <br /> .. ' <br />